Capsule Endoscopy Guidelines

EviCore covers small‑bowel video, colon, esophageal and wireless motility capsule endoscopy only for specified indications (e.g., suspected/known Crohn’s with supportive biomarkers or suspicious ileocolonoscopy/imaging, refractory/discordant celiac disease, obscure GI bleeding after negative EGD/colonoscopy, small‑bowel tumors/hereditary polyposis surveillance, selective colon capsule when colonoscopy is high‑risk or incomplete, esophageal capsule only when EGD is contraindicated, and motility capsule after structural causes are excluded) and excludes use for chronic abdominal pain/diarrhea alone without biomarkers, colon capsule for CRC screening, esophageal capsule as a first‑line substitute for EGD, and motility capsule in patients with bezoar/swallowing disorders, recent GI surgery, Crohn’s, implanted electromechanical devices, suspected obstruction or other listed contraindications. Authorization requires comprehensive documentation (history/physical, relevant labs such as ESR/CRP/fecal calprotectin or celiac serology, prior endoscopy and imaging/pathology reports), specialist attestation when specified, adherence to frequency/surveillance limits, and use of the appropriate CPT code.